Case Study: Pakistan’s first ‘antibiotic footprint’ analysis

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Just like our carbon footprint monitors the global environmental impact of harmful greenhouse gases, we also need to track our antibiotic footprint to contain and reduce the effects of drug resistance.

Supported by the Fleming Fund, DAI Pakistan, conducted the first national Antibiotic Footprint Analysis, modelled on the carbon footprint concept, as an advocacy tool to communicate the risk of antimicrobial resistance (AMR).

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A multi-disciplinary technical team of researchers - from pharmacy, public health, and biomedical engineering - at Boston University worked with DAI Pakistan to provide a comprehensive One Health study based on antibiotic footprint surveillance data from antimicrobial consumption (AMC) for human and animal use in Pakistan.

The antibiotic footprint campaign has raised public awareness of antibiotic consumption and the link to AMR; providing evidence that affects antimicrobial use (AMU) practice and informing healthcare policy in Pakistan.

Pakistan is currently classified as lower-middle-income and is the world’s fifth most populous country, estimated at 221 million people and over 1.5 billion livestock (mostly) cattle and poultry. Livestock contributes around 11% to Pakistan’s GDP, highlighting the important role of agriculture in its economy.

Health services were decentralised in mid-2018 - almost 70% of health services are private, with a high non-reimbursable out-of-pocket expenditure alongside unrestricted access to over-the-counter antibiotics, and rising medicine costs. These factors exacerbate the high burden of AMR found in Pakistan - as in other Southeast Asian and African countries. For example,  World Health Organisation GLASS data in 2019 shows the prevalence of E. coli resistance to Ciprofloxacin was 85.3% in bloodstream infections and 72% in Urinary Tract Infections.

Lack of integrated data

Recognising the challenges of AMR, the Government of Pakistan committed to a National Action Plan on AMR in 2017, but there are visible gaps across One-Health dimensions, particularly concerning animal health – an important sector of Pakistan’s economy. The lack of integrated, comprehensive antibiotic consumption data from human and animal health sectors drove the development of the Antibiotic Footprint analysis.

Data management from both sectors was performed in-silos with separate management information systems. The first national-level 'Footprint’ analysis of Pakistan aimed to bridge these knowledge gaps, inform evidence-based policies, and promote responsible antibiotic use through a One Health approach. Accurate assessment of antibiotic consumption from the ‘Antibiotic Footprint’ raises the importance of lowering AMC across sectors; however, data accessibility is key.

Mutiple strategies

The Antibiotic Footprint Analysis tool provides data-driven insights into AMR reduction and control, suggesting targeted strategies for responsible AMU in human and animal sectors.

Assisting in curbing the emergence of resistant bacteria, the tool estimates and visualises AMC in human and animal sectors using key data sources: pharmaceutical sales, antibiotic imports, and multi-level surveys.

AMR advocacy

The elevated level of AMC points to necessary antimicrobial stewardship. For example, a substantial proportion of imported medicated animal feed is unregulated and requires policy intervention. Using the analysis tool to estimate and visualise AMC data provides an ‘antibiotic footprint’ that can easily be compared against other countries and, for public communication to reduce overall antibiotic use and manage AMR effectively.

Policy reform

Developing the methodology for the antibiotic footprint research, its results prove the critical bottleneck to reliable AMC: lack of high-quality data availability and accessibility.

The study indicated that if antimicrobial sales data for human and animal consumption reporting becomes mandatory, researchers and policymakers can identify specific, contextual, and implementable policies to tackle AMR. South Asian countries, such as Thailand, have made this a requirement – leading to wider availability of AMR surveillance data and enabling beneficial One Health decision-making.

The antibiotic footprint research report has been used as a policy advocacy tool in national-level health consultations for Pakistan. As part of the National Action Plan for AMR revision, the tool should ensure strengthened collaboration among partners, and resource allocation, and foster sustained commitment to responsible antibiotic use and AMR control.

This model could be extended regionally, contributing to a greater understanding of AMC and AMR with effective clinical and societal strategies and further influencing One Health policy across South Asia.

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